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Comment by stuckagain | Hacker News Reader

This idea is based on healthcare not being a scam. You can ask for a price and then will tell you a price but even if you pay that price, up front, in cash, you will later get bills for more "services", received or perceived. In any other industry people would go to prison.

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Yes. My wife recently went for a physical, something covered fully under our plan. We were surprised to see a bill follow and a separate consultation charge (not covered) alongside the physical charge (covered and zero rated). It turns out because she asked the doctor a question the doctor decided that was outside the scope of the physical and constituted a separate consultation. Of course how you're supposed to know what is or isn't in scope I have no idea.

I can one-up you: I had a doctor start up a conversation about going to the same college I did, which put the physical at just over 15m instead of just under, which doubled the bill. I don't think the doctor was maliciously driving up the price, just too abstracted away from the billing department.

How is that one upping at all? That seems quite reasonable and accidental.

he's just mentioning that the fact that doctors are not the ones billing you could cost you double or more.

I just meant one-upping the absurdity of his story, not like his internet points or whatever it is you think I meant.

His wife got charged more for asking a doctor a single question. I got charged more for a doctor asking me a question.

not trying to prod but just curious what was the general nature of that question she asked?

Anything that turns the "preventative" visit into an "evaluation and management" visit will often result in additional charge since they have different billing codes. Preventative visits are usually free under the ACA, but the E/M visit will require a co-pay. My parents moved and were looking to get an annual physical, and most of the clinics they called said up front that they would require a separate, paid, "meet the doctor" new-patient visit before they would schedule for a annual physical, even though they didn't want to have any of their conditions managed and just wanted an annual physical exam.

At open enrollment this year, our insurance rep explicitly told us not to ask questions at the yearly physical. Absurd.

Wow. Had the same experience. I thought it was a joke. He literally said "anything you say can be billed against you" like it was a detective show or something.

I had no idea this was a real thing! So doctors must be added to the list along with tax collectors and police where you just stay quiet during confrontations. Wow.

And we wonder why we have such bad health outcomes in the US

I had to fill out a waiver before I took my last physical that acknowledged anything outside the standard physical would be billed separately. It looked like it was part of a federal standard - the Center for Medicare and Medicaid Service's National Correct Coding Initiative. Your doctor should have some discretion though.

I had the same experience. As a part of small talk at annual physical, I asked a question to the Doctor to which they gave an answer which I already knew ("You do not need to worry about this"), and I got charged for that.

My workplace pays me incentive money for getting an annual physical. So, now I just go to physicals, stay quiet just so that I get the incentive money.

I wonder how doctors feel that their patients are scared of asking them any questions.

This is a little sketch - if the question you asked didn't required any additional work (specialized physical exam, detailed history taking, additional medical decision making), billing for it as a separate evaluation and management visit (as opposed to a preventative visit) isn't kosher. Often people come into their preventative visit wanting to discuss their insulin regimen, blood pressure history or a new acute problem, and this is the situation where the second charge is appropriate.

if the question you asked didn't required any additional work [such as] medical decision making

That effectively of reduces the scope of meaningful questions I can a doctor to near-zero, right?

same for me. HSA with seed + incentive (i think i also guess where you work :)). I think some institutions like PAMF might be doing this more than others, at least that's my observation. i swore for not going there unless it's a medical emergency.

exactly this. happened to my wife as well.

As a healthy person, my lesson learned is do not ask doctor a question, unless you have legitimate reason.

It's also not a service people can easily "shop around" for in an emergency, or go without. Heck, the information asymmetry, alone, between the buyer of the service and the person offering it (that is, the information required to evaluate if they're getting the correct treatment at an appropriate cost) ensures the market will not be a fair one.

Anyone who's gone to a mechanic that's performed unnecessary work knows what that's like... and that's just a car.

The current situation isn't like a mechanic at all. If a mechanic tells me I need some work done, I can call various mechanics and ask what they would charge to do that, and they'll tell me.

If you try that with a hospital, they'll tell you no. Go ahead and try asking your doctor what something will cost.

If I could ask for a price up front, then people who aren't in an emergency could shop around. That would force hospitals to actually compete, which would normally mean most providers would be within a range of the average market price.

So when an emergency does occur and you were taken to a random hospital, chances are that hospital would have prices close to the market price.

My comment about mechanics was specifically with regards to information asymmetry.

That is, 99% of people do not know enough about cars to determine if they are being fleeced.

Now imagine dealing with the human body.

Information symmetry leads to market failures:

https://en.m.wikipedia.org/wiki/Information_asymmetry

> If you try that with a hospital, they'll tell you no. Go ahead and try asking your doctor what something will cost.

My experience is they will tell you, and you can ask for a better price, and I've always gotten one.

The idea that one cannot negotiate with the hospital, the doctor, and the dentist is just incorrect. Try it next time.

I've noticed that insurance pays at most 50% less, in many cases much less than that. And the medical provider accepts it.

Your experience is literally unbelievable to me. I don't doubt you, I just cannot believe there isn't more to the story.

In another comment you seemed to indicate that you are perhaps uninsured and paying cash for everything? That would go a long way toward explaining why you have experiences that run dramatically counter to almost everyone else on this thread. It also seems like important information to be included, if so.

I am insured. You can opt to be billed by the provider, and submit the claim yourself. If you're unsure how this works, read the contract you have with your insurer, or call them on the phone. They may also be able to give you advice on negotiating for lower bills - after all, that lowers their cost as well.

I have a high deductible, so usually wind up paying the entire bill out of pocket. There's no reason to go through the insurer for that.

In general, doctors find the system as bewildering as you do. They might be able to give you a ballpark figure but you'll need someone in the billing department for a hard figure (if you can get one at all). Although they will still likely need an exact billing code for the procedure first.

Right now you shop at the copay level as a function of insurance. PPOs were a great scam to force coinsurance onto the masses.

Most health care is not delivered in an emergency.

And even when it is an emergency, prices for everything could still be made available.

Hospitals do decide how much they are going to charge for everything before you get the particular procedure. It's just not published.

If they won't tell you, tell them you're going to their competitor hospital. That's all it takes to loosen things up.

It's not even the same ballpark. At any reputable mechanic you can get a diagnosis done for free or low cost, and there exist books that estimate the time cost and replacement parts needed for pretty much every repair. There are some known unknowns going into it, like finding worn parts that need to be replaced, but I find that auto repair shops are pretty upfront about possible additional costs. I haven't had any similar experiences in healthcare; I don't think I've ever gotten an answer from a medical practitioner or office manager about the cost of a visit, procedure, lab work, or to what extent it would be covered by my insurance. Even for a vertically integrated HMO like Kaiser, simply no-one you can talk to knows.

I have asked, and also asked for a discount if I paid on the spot. You can often get a third off the price that way - just by asking.

It's the same with auto repairs. I'd take my car to the dealer for repairs, the service dept quotes me a price, I say that price sounds a little high, the price drops 30%.

In any negotiation, you're going to get the sucker price if you don't ask what the price is, or make no attempt to negotiate. Nobody is obliged to give you their best price automatically.

If you don't mind me asking, what kind of medical office/procedure were you able to get a cash price and discount on, in what setting, and which employee did you ask? I've never heard of that happening in the US before the fact; I have heard about negotiating down your medical bill with hospitals after the services have been rendered, though that seems like a crapshoot to me.

One example was having a skin lesion removed, a surgical procedure. I asked the dermatologist/surgeon, it was a procedure she did in her facility.

Another time I visited a neurologist, the woman behind the checkin front desk told me what it would cost. I said that sounded high, can I get a discount? She chirped sure, 30% off for cash on the spot.

Doctors routinely offer discounts for cash on the spot, because then they don't have to deal with patients who are slow payers or don't pay at all.

If they don't, find another doctor. They aren't rare. Heck, dentists are always advertising and offering discounts. They're businesses.

You can get at least 3% off just by using a check, because then they don't have to pay 3% tribute to the credit card company.

I don't recommend being an ass about it. Just be nice and ask for a discount.

"You can get at least 3% off just by using a check, because then they don't have to pay 3% tribute to the credit card company."

Tried this by offering cash on some kitchen remodeling work we were doing. I was talking to the sales person and - we were already going to buy - but I asked if they offered cash discount. She got flustered - almost insulted - "these are our best prices!". I tried to explain running $4000 was going to cost them probably close to 4%, and I have more consumer rights re: chargebacks if I'm not happy. $100 off? $150 off? Nope... flat out refusal ("that's not the way we work!"), so we paid with the credit card. But they just lost that money anyway. :/

Negotiations don't always work, that's for sure. But it is a learned skill, and one can get better at it. There's a good book on it, "Getting To Yes".

AIUI, if you take Visa, you aren't allowed to advertise a lower cash-only price. So maybe they were freaked out about losing the ability to take cards.

Also, I'd be concerned about a personal check for that amount. The last car I bought I put $2K on my miles credit card (the max they would take) and a check for the rest. They made me fill out loan paperwork anyways so that they would have recourse if the check bounced.

i paid for a car with a check ($11k). they just held the title until the check cleared...?

That's interesting, thanks for sharing. Maybe it's common with specialists, but I haven't had that experience with things like X-rays at my GP (before I was kaiser) or anything at Kaiser, like getting blood work done in the ER. I definitely shop around for dental procedures/don't pay for dental insurance, but there's no tax penalty for not carrying dental insurance..

Can't reply for walter but...

I've had a few experiences over the last decade with healthcare services. Had a consultation, some bloodwork and a other bits and bobs - nothing serious. Got a bill a month later for.. $430. This was done through insurance from my employer at the time, but my portion was still ~$430. I went to their office and said this was a little more than I'd be able to pay quickly (not a total lie - would have hurt at the time). Office manager there said "if you can pay cash we can call it $300 and be done with it". I paid the $300 cash and it was fine. This was a small private dr office in a professional office plaza place. Looking back... they could wait another few months for $430... and maybe have to take me to collections, or take $300 cash on the spot. Whatever averages they saw on collections, this was probably not a bad deal.

Few years later, I have same insurance provider, but self-employed, so 'individual/family' plan. My wife got very sick, and we ended up in ER. X-rays, drips, sent home with medication, etc. Got a bill almost 3 months later for ~$3000. Called hospital and asked for some sort of discount. I got (same line from 3 different people on different tries) "this already is a discounted price, because you have insurance, these are the negotiated/discounted rates". Looking more closely at the paperwork, the 'retail' price was somewhere north of $5000, but the insurance company's 'negotiated' rate was ~$3000 ($2800 IIRC).

It never hurts to ask, and maybe ask a lot, but it's not some magic "you'll always pay half price by just asking for a discount". And the point many others have made before - when you're having to go to ER, you don't have the luxury of shopping around, and generally the majority of folks you're seeing there are in no way cognizant of billing/pricing stuff (especially on a sunday when we went).

Here's the problem. If you do it outside your insurer, it no longer applies to your deductible. If your annual procedures don't hit deductible anyway, you come out ahead by getting the discount. Otherwise you'll pay more out of pocket for the unclaimed procedure.

It's worth having a talk with your insurer to be sure how that works in your case, as every plan is different.

Of course, it's easier to do a diagnosis with a car, cars are much better understood than human physiology. Medical science recently discovered (well, recognized) a new organ in the body.

I went to the doctor for a non-specific illness. The doctor ran $3000 worth of tests, and by the time the last of the test results came back, it had gone away. The doctor shrugged and said "Huh, I dunno what that was. Probably some kind of infection".

Some things are more clear (i.e. a broken arm), but if it doesn't heal well and the $1000 estimate for an X-ray and a cast turns into a $10000 surgical procedure plus 6 months of therapy, are you going to expect the doctor to just eat the cost? Are you going to shop your painful broken arm and medical records around to 3 different doctors to get a new estimate?

I believe they have to give you a written estimate, and if costs are gonna exceed that by 10 or 20%, they have to get authorization from you, and so on. Completely unlike health care.

And yeah, there is a "book value" for repairs (body and mechanical). Sometimes they can do it faster, sometimes much faster. They're charging you retail price for parts, not wholesale. Etc. Of course you can negotiate and save money, but it's worlds different from health care.

Doctors that specialize in things insurance rarely covers, like cosmetic surgery, are often quite upfront with costs. The complexity of insurance seems to be a big part of the problem.

And you see that with cars too. If someone is having an ordeal related to auto-maintenance, you often hear insurance mentioned...

It's compounded by the fact that you often don't have any real flexibility in how you fix the problem.

To extend your analogy, let's say I want to fix a broken headlight. I know how to do this, and can get better headlights than the one that would be offered through the two mechanics in my neighborhood. I can do this myself more cheaply. Or maybe my friend who used to work as an airline mechanic wants to do it as a favor. Or who knows.

With medical care, you might realistically only have one option due to problems with insurance coverage, so even if you were given the price, you'd have no choice. But even if you had two choices, you don't have a third option because it's legislated away. If I need my medication that I've been taking for four years without any problems, and it's a low risk med anyway, why should I have to go to see a PA, NP, or MD to get a prescription for it?

It's not just that the costs are opaque and hidden, it's that you are legally mandated in certain respects to accept them. The alternative is generally only to not have the service done.

Imagine that you get charged for a $600 gown after the fact, but you can get that same exact gown from the manufacturer or any other company for $80 -- You should be able to reimburse the hospital to replace this item at that cost and a max of 20%... this would keep them from raping people on items of no importance.

There is way too much money in the current system for pricing to become legitimate. All the waste and overcharging is someone's profit. And the Republicans certainly won't do anything about this in the next years. Because "regulation" is bad.

It is the way that the licensed practice of medicine is so heavily regulated that creates the noncompetitive environment in the first place.

Though I wouldn't expect Republicans to ever admit that, at least congressional ones. If the regulation existed under Reagan its the best thing ever (see: if establishment corporations abuse it) and if wasn't its communism (see: donor corporations don't want to be regulated).

The services are too expensive, yes, but that's not what I'm getting at. I'm saying that even the inflated sticker price won't prevent tons of random other bills from flying out of nowhere. Once I got an anesthesia bill -- for almost ten thousand dollars -- after an event that didn't involve anesthesia, at which the anesthesiologist was not even present. There was just some stored procedure in their database that fired off bills.

The financial part of medicine seems pretty unregulated. They can charge phantasy prices and frequently charge for services never delivered without consequences. In other industries this would be plain fraud.

An insurance free market would fix this. Everyone knows that.

Except, of course, you shouldn't be able to buy over state lines. That's for your protection for some reason.

And once everyone has free market insurance then everything will be fine. You'll be able to choose the plan that can help you cover your bills.

Your bills will still be generated by a labyrinthian and byzantine system that no one including the people in charge of running it actually understand driven heavily by profits, phases of the moon, insanity, and corn prices.

But you'll have free market insurance (sort of)! So everything will be fine!

Realistically, I get the feeling that we've found new ways repeatedly to direct our system down blind allies to the point where I wonder if we can ever find our way back out without a massive disaster/collapse.

>You can ask for a price and then will tell you a price but even if you pay that price, up front, in cash, you will later get bills for more "services", received or perceived. In any other industry people would go to prison.

Not arguing with you, but there's another field where this is common: Law.

I haven't ever got a surprise legal bill, and I have a fancy famous lawyer that you've heard of. I don't think there's any comparison.

Happened to a friend of mine who shopped around and got a commitment in advance for the price. He reminded them of their commitment after they billed him for all the extras, and refused to pay it. They withdrew the extra charges.

He's lucky they just didn't send it to collections as many institutions would do if a patient refused to pay.

The hospital had no case as they had made an agreement. Collection agencies cannot collect money that you can document you do not owe.

I can't believe a doctor or hospital would agree to such a commitment. If the doctor wants to do an extra test or procedure to make sure the treatment is working as expected, then he's in a bad spot -- he either does it for free, or he faces malpractice liability if there is a bad outcome, regardless of any contract you may have signed with him.

The extra charges were bullshit, they were not the result of complications or other unforeseen circumstances.

This is not common. Not sure why you feel so compelled to disagree with all the other posters regarding their headaches with healthcare billing/cost experiences throughout this thred. Odd.

I contacted multiple hospitals for cost estimates on a simple procedure (hours of phone calls) and only one would actually give me an "estimate." They went out of their way to explain that this was only an estimate and it could easily end up costing more than this due to a number of factors.

I really doubt any hospital will ever give you a committed price for any procedure. I would love to be proven wrong from any other posters :).

Get the estimate in writing and then compare it with your bill. If there are more charges, they'll need to explain how those are unforeseen factors, or you can legitimately refuse to pay for them.

You can also show the estimate to other hospitals - this will often loosen them up about quoting a price because they'll want the business.

Uh, what? There is nothing binding about the estimate (unless you're in the auto repair industry), so you cannot "legitimately refuse to pay for it" unless they explain "how those are unforeseen factors".

Typically, indeed, you'll find wording to that exact effect. "This is only an estimate. Actual costs may differ."

Ask for a binding estimate.

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